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Delivering Race Equality: DIVERSE APPROACHES TO DIVERSE COMMUNITIES.
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The Central and North West London (CNWL) NHS Foundation Trust’sFocused Implementation Site (FIS) was one of the 18 FIS Projects that were the vanguard of the UK’s Department of Health’s Delivering Race Equality Action Plan launched in 2005. CNWL provides adult mental health services and a range of older peoples, child and adolescent mental health and addictions services across a number of London boroughs, including, Brent, Harrow, Hillingdon, Kensington & Chelsea and Westminster.
This presentation is a brief account of the project’s outcomes. The full evaluation report can be found on the Trust’s website: http://www.cnwl.nhs.uk/equality_diversity_news.html The CNWL FIS Project was one of the few national FIS sites to be based solely within a mental health Trust. The Project is also significant in that CNWL mental health services cover some of the most ethnically diverse boroughs in the UK, Brent is the most ethnically diverse Borough in London, Harrow the most religiously diverse.
Admissions 2007/8 by ethnicity to CNWL adult mental health in-patient services
THE FIS Plan, Do, Study, Act cycle The CNWL FIS Project from the outset was conceived as an approach to system-wide change through testing small scale projects and interventions. These were to be regarded as stepping stones to introducing improved practice on a mainstream scale by promoting the learning from these small scale projects both across the organisation, and nationally. The FIS Project was not an academic research project but service development initiative
What were we looking at? • A reduction in the disproportionate rate of admission of people from BME communities to psychiatric inpatient units & A reduction in the disproportionate rates of compulsory detention of BME users in inpatient units 2. A reduction in the proportion of prisoners from BME communities 3. A more active role for BME communities and BME service users in the training of professionals, in the development of mental health policy, and in the planning and provision of services 4. A workforce and organisation capable of delivering appropriate and responsive mental health services to BME communities The above are identified characteristics of a reformed mental health service, as envisioned by the UK Department of Health’s Delivering Race Equality agenda. Please note: BME stands for Black or Minority Ethnic
How did we do it?An example – a process map for improving the Black African and Black Caribbean In-patient Journey
1. Responding to disproportionate admissions In some areas of the Trust there was evidence of reducing admission/ detention rates of Black service users. ‘Count Me In’ Census figures for 2005 and 2007 showed that Trustwide Black in-patient over-representation was falling. The rise in Harrow was based on very small numbers of detained patients in this group, making the very small rise in the number of detentions over the period produce a large proportional change.
1. (cont) Responding to disproportionate admissions CNWL was already developing assertive outreach, early intervention and crisis resolution teams and evidence is that these are treating significant numbers of Black service users. Community Mental Health Teams were not a significant cause of over-representation of Black service users on in-patient wards. It was realised that perhaps the Trust could make a more significant impact by addressing re-admission by ensuring appropriate and culturally competent support and care planning within wards with supportive links being established to the community ahead of discharge.
1. (cont) Responding to disproportionate admissions Brent Mental Health Service launched a series of initiatives on one of its in-patient wards in October 2009 to improve the Black patient experience. This, coupled with more culturally appropriate discharge planning, we hypothesise will lead to reductions in re-admission. These initiatives include: • The African & Caribbean Community Network Services working with staff and service users on the acute admission wards to ensure that on discharge service users are supported in accessing the social inclusion programme’s six life domains (faith, cultural communities, education & training, employment & volunteering, art & culture and sports and leisure).
1. (cont) Responding to disproportionate admissions • A Monthly Recovery Group (“Hope Project”) for Black British, Black African, Black Caribbean and other black service users in the inpatient units where motivational speakers are invited to attend. • New Roots (a substance misuse service for Black service users) information sessions. • A Survey of clients to ascertain how the move-on care package can be improved. • Primary Care Liaison Team working in liaison with Safer Neighbourhood Police Officers re referrals for home treatment. • Increasing the uptake of Self Directed Support and Direct Payments by this client group.
2. Responding to reducing BME prison admission through improving court diversion • From auditing equality and outcomes from our existing Court Diversion services in Harrow and Brent, we found that Black African and Black African Caribbean defendants referred to us had a slightly improved chance of being diverted compared with all other ethnic groups. • Combining this work with a parallel project, CNWL became a national pilot for developing a Service Level Agreement for Psychiatric Court Reports, • CNWL is currently working on a service redesign to produce a single Court Diversion service that covers Brent, Harrow and Hillingdon. • CNWL developed a partnership with a local community organisation in Brent - PLIAS (Prison Liaison Information and Advice Service) - who work with Black-ex-offenders. We have supported them with organizational development and jointly produced a report on the experience of BME service users with an offending history and mental health problems who have poor contact with the statutory services. This highlighted their fear of mental health stigma and fear of racism.
3. Responding to developing a more active role for BME communities In Brent, the FIS Project held an event organised in partnership with Brent Multi-Faith Forum that included representatives from a variety of local faith communities and resulted in a report containing 5 key recommendations from the faith communities. Subsequently these recommendations included in the Brent Mental Health Service Business Plan for 2008/09, were to: • Work with users of mental health day service to develop support from faith communities. • Monitor the assessment of faith needs • Identify & develop 5 faith groups to work in partnership with the mental health services. • Provide Mental Health Awareness Training for these 5 faith groups. • Train at least 80 mental health staff on Faith Competency in the next 12 months.
3. (Cont) Responding to developing a more active role for BME communities In Harrow, the FIS Project developed the Asian Mental Health Reference Group (form of Community members and CNWL managers) to identify issues of concern for the Asian community. The group designed a local conference on mental health in the Asian Community and subsequently embarked on a work plan with Harrow Mental Health Services to take forward the recommendations from the conference. This and other community work in Harrow was recognised by a Community Cohesion award at a recent national ceremony (Feb. 2010). In Westminster and Kensington & Chelsea working with the BME Health Forum’s BME Community Group Leadership Development Project on a project aimed at changing GP/Primary Care practice across Westminster and Kensington & Chelsea in response to recommendations from ‘Primary Concern’, a research report by the BME Health Forum on access to GP/Primary Care services by BME patients.
4. Responding to developing a workforce capable of delivering a more appropriate and responsive service The FIS Project was involved in the assessment of an e-learning approach to training in basic Diversity Competence in the workplace across the Trust. To date over 800 staff have completed the module. The intention is for all CNWL staff to complete the module and for it to be mandatory for all new staff. The FIS Project and the CNWL Head of Equality and Diversity have designed and developed a Cultural Competency Training Programme for Managers and a supporting handbook. This uses ‘live’ case studies to ensure relevance, and the training is inclusive of race/ethnicity, disability, gender (including trans), religion or belief, sexual orientation and age. To date over 100 Trust managers have attended this training.
4. (Cont) Responding to developing a workforce capable of delivering a more appropriate and responsive service A further 2 pilots have been conducted of an adapted programme on ‘Cultural Competence for Doctors’. Guidance for doctors has been produced on how to ask about cultural needs, based on feedback from the first pilot session with doctors. We are now exploring how we engage this programme with the local academic training of doctors as well as continuing with the corporate level training sessions. In addition, a presentation addressing the stigma of mental health within a culturally diverse context was produced, and has been used to raise awareness amongst CNWL staff.
Learning from the community (1) The strong message from our community group partners in their contributions to the FIS Evaluation Report was that the mental health services need to invest in partnerships with local community groups to create visible change in services. Community groups have been substantially involved as a resource to the FIS Project providing invaluable knowledge, expertise, enthusiasm and ideas and they have welcomed and appreciated the Project’s support. The cliché of ‘hard to- reach’ communities has been radically challenged by the CNWL FIS Project’s experience to illuminate how much mental health services can appear to be ‘hard-to-access’ organisations who seem indifferent to local communities’ concerns.
Learning from the community (2) During the course of its three years, the CNWL FIS Project made links to 33 community groups that had not previous had links with their local mental health service. As a result CNWL has made substantial gains in understanding and communicating with Black and Minority Ethnic communities and experiencing the benefits that can be gained from working with community groups as partners. It can require persistence and openness to encourage trust. Communities need to be encouraged by tangible evidence that their involvement leads to changes and developments. Communities rightly need to feel that something is being given back to them through their involvement. This improvement in communication is an essential first step in improving and delivering better and more appropriate services.
National / International Recommendations Recommendations (1) Routes into admission and compulsory detention should be compared with detailed local ethnicity data and work developed in partnership with local BME groups in designing service changes Place a focus on supporting ‘moving out’ processes, including robust culturally competent Care Programme Approach (CPA) to improve chances of sustaining recovery by ensuring connections are made with culturally appropriate community networks, including faith communities, and appropriate housing, education and employment opportunities Recommendations (2) Local mental health services should explore options for more direct alliance and partnership work with Black 3rd Sector providers, including faith communities Develop effective Court Diversion services in all regions. Develop Court Diversion capacity to reduce use of remand in custody for the purpose of assessment for psychiatric reports
National / International Recommendations National recommendations (4) Cultural Competency Training should be attended by all mental health managers and senior clinicians from executive to ward level, and learning cascaded through line management and supervision processes, team meetings and case discussion. ‘Culturally Competent Practice’ Support Networks be established to support managers Cultural Competence training should be relevant to the experiences of services, based around ‘live’ situations that are arising in service provision and should be inclusive of all the diversity strands (race, disability, gender, religion or belief, age and sexual orientation) as a more accurate reflection of individual’s experience. National Recommendations (3) Mental Health Trusts should take a fuller direct role in raising local awareness about mental health as a way of breaking down fear of local services and creating a dialogue with local communities. Corporate and local links with BME umbrella groups/networks need to be complemented by developing direct links with individual BME community groups that are not previously known to have links with the organisation.
for further information contact: email@example.com or firstname.lastname@example.org You can access the Full Evaluation Report at http://www.cnwl.nhs.uk/equality_diversity_news.html